脊髓黏液乳头型室管膜瘤的临床特点和治疗(附11例报告)

目的 探讨脊髓粘液乳头型室管膜瘤的临床特点和治疗方法.方法 回顾性分析北京天坛医院神经外科收治并获得随访的11例原发和复发脊髓黏液乳头型室管膜瘤患者的临床特点、治疗和预后.结果 本组11例患者共接受17次手术,首次手术全切3例,近全切除6例,大部切除1例,部分切除1例.术后接受放疗7例,同时接受化疗2例.术后平均随访38.1个月,无死亡病例,原位复发2例,播散转移2例,再次手术切除.结论 脊髓黏液乳头型室管膜瘤容易复发和播散转移,最有效的治疗方法是完整切除肿瘤.无法全切除病变建议放射治疗.     

显微手术治疗脊髓室管膜瘤预后的影响因素分析

目的 探讨显微手术治疗脊髓室管膜瘤的疗效及影响预后的因素。方法 对手术治疗的80例脊髓室管膜瘤的临床资料进行回顾性分析,参照欧洲脊髓病评分（EMS）和McCormick分级评估手术前后脊髓功能;采用多因素Logistic回归分析检验预后影响因素。结果 肿瘤全切除51例,次全切除25例,大部分切除4例。术后平均随访（37.6±19.0）个月,复发5例,均为WHOⅡ级,复发时间为（58.4±43.1）个月。末次随访有49例脊髓功能较术前改善,19例无变化,12例加重。术后McCormick分级:Ⅰ级35例,Ⅱ级22例,Ⅲ级12例,Ⅳ级11例。多因素Logistic回归分析发现,术前存在大小便功能障碍是不良预后独立危险因素,而伴脊髓空洞是预后良好因素。末次随访EMS[（15.01±0.3）分]明显高于术前[（13.55±0.35）分;P<0.001]和术后3 d[（13.20±0.31）分;P<0.001]。结论 脊髓室管膜瘤显微手术治疗后脊髓神经功能在短期内以趋于稳定为主,但从长远来看,显微手术能有效治疗脊髓室管膜瘤。存在大小便功能障碍的室管膜瘤建议及早手术治疗;伴有脊髓空洞的脊髓室管膜瘤手术预后良好。     

包膜外整体切除技术在脊髓室管膜瘤手术中的应用

目的 探讨包膜外整体切除技术在脊髓室管膜瘤手术中的应用效果。方法 回顾性分析2018年9月～2020年2月应用包膜外整体切除技术手术治疗的14例脊髓室管膜瘤的临床资料。采用McCormick分级评估脊髓功能。结果 肿瘤全切除13例,次全切1例。术后随访12个月,未见肿瘤复发。术后7 d,脊髓功能改善4例,稳定7例,恶化3例;术后3个月,脊髓功能改善9例,稳定4例,恶化2例;术后12个月,脊髓功能改善11例,稳定2例,恶化1例。结论 在脊髓室管膜瘤手术中,包膜外整体切除技术,有助于提高肿瘤全切除率、减少肿瘤复发风险。     

第四脑室室管膜瘤的临床特点和治疗(附19例临床分析)

目的探讨第四脑室室管膜瘤的临床特点和治疗方法。方法回顾性分析2011年1月至2015年12月安徽省立医院收治的19例第四脑室室管膜瘤患者的临床特点、治疗和预后。结果首发症状多为头痛、呕吐等高颅压症状,常伴有梗阻性脑积水。本组患者肿瘤全切除12例,次全切除4例,大部切除2例,部分切除1例。无手术死亡病例。术后接受放疗9例,3例还接受了化疗。术后随访16例,平均随访36.2个月,复发5例,再次手术2例,死亡4例。结论第四脑室室管膜瘤容易复发,治疗应采用手术联合放疗。复发患者可再次手术。     

脊髓圆锥区室管膜瘤的显微手术疗效分析

目的 探讨脊髓圆锥区室管膜瘤的显微手术疗效。方法 回顾性分析2012年1月至2021年12月显微手术治疗的27例脊髓圆锥区室管膜瘤的临床资料。结果 肿瘤全切除14例（51.9%）,次全切除4例（14.8%）,部分切除9例（33.3%）。术后病理均诊断为室管膜瘤（WHO分级Ⅱ级23例,Ⅲ级4例）。术后随访（40.44±28.7）个月;全切除14例中,1例术后3年复发;未全切除13例中,3例保持稳定,10例进展。末次随访,神经功能状态McCormick分级Ⅰ级14例,Ⅱ级7例,Ⅲ级2例,Ⅳ级2例,死亡2例。结论 对于脊髓圆锥区室管膜瘤,早期在神经功能良好的状态下全切除肿瘤能够取得较好的疗效。如条件允许,建议行全基因组检测,结合组织学分型,能够更好地指导临床。     

原发性脊髓黏液乳头型室管膜瘤的诊断和治疗

目的 探讨原发性脊髓黏液乳头型室管膜瘤的临床特征和手术治疗.方法 回顾性分析复旦大学附属华山医院神经外科2008年1月至2012年12月收治的18例原发性脊髓黏液乳头型室管膜瘤的临床特点、诊断、手术治疗及预后.结果 本组18例患者手术全切除15例,次全切除3例.术后均未行放疗和化疗.术后15例获得随访,平均随访32个月,无术后复发、转移及死亡病例.结论 原发性脊髓黏液乳头型室管膜瘤为少见类型室管膜瘤,遵循正确、合理的操作方法全切后可获得良好预后.     

脊髓室管膜瘤的临床特点及显微手术治疗效果

目的 探讨脊髓室管膜瘤的临床特点、显微手术效果.方法 回顾性分析2015年12月至2019年4月显微手术治疗的30例脊髓室管膜瘤的临床资料.结果 病程1个月至10年,平均(17.73±23.99)个月.首发症状为疼痛25例,感觉障碍14例.肿瘤全切除26例,次全切除4例.26例出院后随访1年,未发现肿瘤复发;末次随访M...     

电生理监测在中央回及其相邻区域胶质瘤手术中的临床应用

目的探讨应用皮质体感诱发电位、皮质运动诱发电位和皮质脑电图定位功能区,提高毗邻脑功能区胶质瘤切除手术的有效性和安全性。方法通过影像学检查筛选18例中央回及其毗邻部位的胶质瘤患者,经功能磁共振成像和脑磁图初步定位功能区;术中以皮质体感诱发电位和运动诱发电位进一步确定脑功能区、脑电图明确致痼灶位置,避开功能区切除肿瘤和（或）致痼灶;术后于瘤腔内植入放射性同位素125I和缓释型化疗药物5．氟尿嘧啶。结果18例患者中1例肿瘤全切除、13例次全切除、4例部分切除。手术后第6、12和24个月疗效评价,无进展生存期平均为11个月;客观有效率分别为13／18、9／18和6／18;疾病控制率15／18、13／18和10／18。手术前和术后第6、12、24个月时的Karnofsky生活质量评分分别为（84．13±12．88）、（78．20±15．13）、（62．35±13．21）和（46．57±16．93）,各观察时间点之间比较差异有统计学意义（P〈0．01）。术后并发症发生率为6／18例（肌力下降2例、感觉减退3例、肌力与感觉同时减退1例）。结论采用术中神经电生理学监测方法定位功能区及致痼灶,可在保留功能的情况下指导切除中央回及其毗邻部位胶质瘤。术后瘤腔内行间质放化疗对延长患者生存期、减少肿瘤复发有一定临床意义。     

脊髓髓内肿瘤及显微外科治疗

目的 探讨脊髓髓内肿瘤的诊断和显微手术切除方法。方法 对16例脊髓髓内肿瘤手术患者进行回顾性研究。结果 肿瘤全切除10例,近全切除4例,大部切除2例,术后12例均有不同程度的改善和好转,1例肌力较术前减退,3例未见明显好转。随访3个月～4年,室管膜瘤复发1例,星形细胞瘤复发3例,其余未见复发。结论 脊髓髓内肿瘤应作显微手术切除,避免或减少脊髓损伤,尽量做到全切除,减少术后的复发。     

经单鼻孔蝶窦入路切除垂体大腺瘤

目的：探讨经单鼻孔蝶窦入路手术治疗垂体大腺瘤的方法与疗效。方法：回顾性分析经单鼻孔蝶窦入路显微手术治疗34例垂体大腺瘤的临床资料,总结并分析肿瘤切除程度、术后视野恢复情况和手术前后血清激素水平变化。结果：术后行MRI、视野复查显示,近全切除23／34例（67．65％）,术后视野恢复好转率91．30％;次全切除5／34例（14．71％）,术后视野恢复好转率80．00％;大部分切除4,34例（11．76％）,术后视野恢复好转率75．00％;部分切除2／34例（5．88％）,术后视野恢复好转率50．00％;术后总体视野恢复好转率85．29％;无手术死亡病例。手术前血泌乳素、生长激素水平下降与手术后比较差异有统计学意义（前者仁2．57,P〈0．05;后者仁3．01,P〈0．05）。随访28例,随访4-73个月,平均27个月。15,28例（53．57％）治愈,10／28例（35．71％）控制,3/28例（10．71％）复发。9例接受立体定向放射外科治疗。结论：经蝶窦入路切除垂体大腺瘤是安全有效的手术方法,能改善大部分患者的视野缺损、能明显降低功能性腺瘤患者的激素水平。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.